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orr sye SAN ..IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT • 1868 Hazelton Avenue, Stockton, CA 95205-6232 .P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address /(p HAr2,0"q WA� City/State/Zip /CA/ Phone Cross Street 6j C igA,61Ja (-y'lMAT AP /30/-p7,tJ -0/d-000 Property Owner' Phone Address 'V57 City/State/Zip s r1! Ze4 C-57 Contractor MT11 /'V4. License# y�S/(r$� Phone Address qS0 lbkylo "u-077 J City/StatelZip ,-9'Zq b 79 ConsultanU9ub-Cnntractor ,e�-/jam/S /�.�� /�✓L. License# Phone Address /ol 4114KLWZ /I/0", /oMZ�7-,Sy/j,,4 200 City/State/Zip /Z4Jf4,//k 1642 GAY CONSTRUCTION WORK TO BE PERFORMED:'Note Offsite BoringsAVeils Require Access Agreements or Encroachment Permits TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporNu'aler) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia Casing Depth: [DINJECTION(Aur suaroe.OzQnml ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? t]Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL-SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLTHAT APPLY) #WELLS TO BE DESTROYED OVER-BORE DIAMETER of inches to depth of feet WELL IDs ni k,9 19-PRESSURE GROUT To depth of_7-0 feet below surface GROUT SPECIFICATIONS 5-119 yol. A,o 9 V16i. ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE CYPIFIE 040USHROOM CAP 3 feet below surface or feet below surface if>3 feet COMMENTS: 1nvN/TYR/nnJ h/p// MW-� �S Gvr �f/J OG`S/TP p✓ // 6 (�,,//o.✓Sri«+/, I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Print Name �jyjTp M_;4' sh py Date 7- DEPARTMENT USE ONLY Application Accepted By Date Issued. Grout Inspection By/Dates: Destruction Inspection By/Dates Facilit /Site Information FA Name FA AddreST7 FA# IPR# FA PE WP Reviewed By I Work Plan Date ❑C 5/ ❑C h7 Au!�owatior for Other to Sian Fermi; ❑Workers Camp ❑Worker's Comp Waiver ❑Erx:roacbmeni Permit ❑Access Agreement ❑Lead Agency Approval ❑1A4 R COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Permit 130 x EHD 29-01 6-23-2015 Site Mitigation Well Permit Application